Historical and Conceptual Foundations of Ethnogeriatrics
3.2 National and International Projections for Racial and Ethnic Composition
3.2.1 General US Patterns
The U.S. Census Bureau (BOC) 2014 projected life expectancy (Table, 2014) at birth for both sexes continues to increase from 2015 at 70.4 years of age to 85.6 years of age in 2060. There are, however, differences when this is considered by racial iden- tity. While those identifi ed as non-Hispanic White had a life expectancy of 80 years in 2015, projections note increased life expectancy of 82.2 years in 2030, and 84.8
years in 2040. Native Hawaiian and Other Pacifi c Islander and Hispanics have simi- lar life expectancy to non-Hispanic Whites at birth; however, Blacks have lower pro- jected life expectancy noting 76.1 years in 2015 and projections of 78.8 years in 2030 and 80.5 years in 2040. Projections of life expectancy at age 65 and 85 in 2012 and 2050 differ consistently by sex and less predictably by race. The BOC notes that the 2012 male life expectancy at age 65 for non-Hispanic Whites, Asians, and Pacifi c Islanders compared to Hispanics and Non-Hispanic Blacks, American Indian or Alaska Native was 18.1 vs. 19.5 and 16.3 years, respectively. Therefore, the most signifi cant difference in lower life expectancy occurs among non-Hispanic Blacks, American Indian, and Alaska Native 65-year-old males. Projections become more similar after age 85 as there is little difference between 6, 7.1, and 6.3 years, respec- tively projected [ 7 ]. Unlike projection for younger ages in the United States, the majority of the older population will continue to be non-Hispanic White. While no single group will make up a majority, older adults collectively not designated as non- Hispanic White are expected to become a majority by 2043. [BOC Projections 2012;
7 ]. “Of those aged 65 and older in 2060, 56.0 % are expected to be non-Hispanic White, 21.2 % Hispanic and 12.5 % non-Hispanic black” [BOC Projections 2012; 8 ]
The conclusion from these aforementioned projections is that the country will be more racially and ethnically diverse (Fig. 3.1 ). Overall, the projections note a steady growth of the non-Hispanic White population that will peak in 2024 at 199.6 mil-
Fig. 3.1 Population by race and Hispanic origin [ 20 ]
lion. However, unlike other groups, a marked 20.6 million decline is expected between 2024 and 2060 (BOC Projections 2012). American Indian and Alaskan Native populations are among some of the smallest populations in the United States.
Despite their low overall population, their older population is expected to increase dramatically from 3.9 million at present to 6.3 million in 2060. The Native Hawaiian and Other Pacifi c Islander population has similar growth projections from 706,000 to 1.4 million (BOC Projections 2012).
Some of the greatest gains in population will be among Hispanics, Asians, and those self-identifying as two or more races (e.g., Biracial). The population of Hispanics will see the greatest increase when “nearly one in three U.S. residents will be Hispanic” and specifc population forecasts predict 128.8 million in 2060 from 53.3 million in 2012. The Asian population also is projected to have formida- ble although more modest increases with a doubling of population of, from 15.9 million in 2012 to 34.4 million in 2060 (BOC Projections 2012). A much more modest change is expected in African American or Black populations with a very small change in overall percentage from13.1 % in 2012 to 14.7 % in 2060 .
3.2.2 European Patterns
The racial, ethnic, or cultural demographic shifts are not limited to the United States. Western Europe has experienced a dramatic increase in the net migration as a percentage of births. Coleman notes that in 2011 there was overall 25 % or between 9 and 81 % net migration in western European countries excluding Spain and Greece, where −9 to −14 % net migration as a % of birth was seen. Projections note that there is a linear increase of the population size of minority groups between 10 and 40 % of the national population by the projection period (usually 2050) [ 3 ].
3.2.3 Geographic US Patterns
The relative racial/ethnic older population geographic distribution may impact workforce needs and healthcare utilization. In general, those over the age of 65, regardless of race, are more concentrated in the upper Midwest and parts of Florida and those 85 years and older are more concentrated in the same areas with the addi- tion of New England [ 9 ]. However, in the U.S., African Americans traditionally have been most concentrated in the southern states and metropolitan areas. This pattern is consistent for both young and older African Americans. In addition, while the proportion of African Americans in the south was noted to increase between 2000 and 2010; conversely, the proportion in the largest principal cities declined during the same time period [ 10 ].
3.2.4 Impact of Immigrants
There are differences in immigration between the United States, United Kingdom, and Europe that are shaped by history and current immigration policy. Nevertheless, immigration is driven by factors including war, economic stability, and restrictive policy initiatives. Many projections of population size and group characteristics might assume that the level of migration would stay constant; however, others might account for major changes based on other factors. While the United States has a possible majority non-White population projected for 2043, the UK projects a pos- sible change of this kind in 2070 and earlier in urban areas and younger age groups [ 3 ]. According to Coleman, Eurostat notes that the European Union (EU) popula- tion of “foreign background” will be between 26.5 and 34.6 % in the year 2061.
Immigration will likely affect the discrete nature of self-identifi cation and result in more individuals of mixed origins. This change is not likely to affect the demo- graphics of the older adult population at this time; however, there might be future shifts for older adults. The multiethnic or heterogeneous ethnicity designation will be noted in caregivers .
The majority of the foreign-born U.S. population is between the ages of 25 and 45 [ 9 ] and their number is increasing. This has signifi cantly impacted the older adult population. According to the U.S. Census data, one of every eight immigrants is an older adult [ 11 ]. Some estimate that there was a change during the twentieth century with a shift from 30.9 % of elderly identifi ed as immigrants decreasing to 9.9 and 13.6 % of the U.S. population identifying as immigrants to 9.5 %. Restrictions in U.S. migration date back to 1875 and include the Chinese Exclusion Act of 1882 and the immigration act of 1891. National origin quotas were abolished by the Immigration and Nationality Act of 1965 [ 11 ]. There has been a signifi cant shift in the composition of immigrants away from European origins and resulted in an esti- mated increase in individuals from Mexico, The Philippines, Cuba, and China. This shift is also appreciated in the older adult population with more individuals self- identifying as Hispanic (30.6 % vs. 3.7 %) or Asian (25.3 % vs. 0.7 %) [ 11 ].
Current twenty-fi rst century estimates note that the number of all immigrants has signifi cantly increased and the number of elderly immigrants is also dramatically rising (Figs. 3.2 and 3.3 ). The U. S. Census Bureau notes that the elderly immigrant population rose from 2.7 to 4.6 million in 20 years, 1990–2010. The Immigration Reform and Control Act occurred in 1986 and was meant to address the unauthor- ized population. Many of the changes in policy have resulted in distinctions between newer and older immigrants and the benefi ts they are eligible to receive. These distinctions have resulted in signifi cant differences among immigrant groups based on their authorized status and differences between immigrants and the native-born population. Many of the income difference might be from social security eligibility.
While many of the longer-term immigrants have nearly the same social security eligibility as native born (80.7 % vs. 88.6 %), the newer immigrant’s qualifi cations and amount of benefi ts differ based on years since immigration and can range from 22.5 to 49.4 % [ 11 ]. Some estimates note that the median income for immigrants over 65 is $12,700 vs. $20,000 of native-born comparisons [ 11 ]. Social security
Fig. 3.2 The U.S. foreign-born population ages 65 and older increased [ 21 ]
Fig. 3.3 Population by selected age group and nativity: 2014–2060. U.S. Census Bureau, 2014 National Projections [ 22 ]
insurance appears to be a safety net for immigrants in the United States for 10–20 years. Treas et al. note that foreign-born older adults have a mortality advantage and lower prevalence of chronic conditions. Despite these advantages, this same group is noted by Treas and colleagues to have worse self-rated health and higher disabil- ity. Poorer self-rated health is especially noted among Hispanics. Hispanics note greater functional limitations, higher rates of many diseases (e.g., diabetes) and lower mortality; a phenomenon also known as the Latino Paradox . Various reasons have been proposed to explain the Latino paradox , including, genetics (they have more diabetes with less heart disease); return to their native home to die resulting in a reduced mortality rate; or is misclassifi cation of data [ 12 ].
The U.S. regional concentration of immigrants has also changed through time.
There have been substantial shifts south and west, whereas the native-born demo- graphic s appear more stable between 1950 and 2000 .
Studies have shown that there are signifi cant differences between native-born and immigrant populations with respect to mortality, marital status, urban residence, educational attainment, occupation, and family income. In a study of all-cause and cause specifi c mortality, morbidity, and health behaviors in United States national databases, Singh and Siahpush [ 13 ] note that immigrants have a lower mortality risk when compared to socioeconomically and demographic-matched native-born whites. There were also differences in disease states, morbidity, and health behav- ior. These differences appeared to lessen with length of time since migration.